Laura Wendte

Case Study T2DM

Case Study Questions for Type 2 dm

I. Understanding the diagnosis and pathophysiology

1. List and briefly describe the 4 general classification categories for Diabetes Mellitus.
-Pre-Diabetes: impaired glucose homeostasis, IFG, IGT, or A1C of 5.7- 6.4%
-Type 1: Immune mediated or idiopathic destruction of insulin secreting beta cells
-Type 2: Insulin resistance and B-cell failure (insulin deficiency)
-Gestational: develops only during pregnancy

2. List the four diagnostic criteria used for the diagnosis of DM. What lab values validate the dx of type
2 dm for this client? If an individual has 1 FBG reading of 128ml/dl do they classify as having DM?
Why or why not?
- FPG >126
- OGTT >200
- RPG > 200 w/ 3Ps
- HgA1C >6.5

- No, they would not qualify for a Dx of DM because you need at least two lab values to validate
the diagnosis.

3. Describe the diabetes testing criteria in asymptomatic adults using the Diabetes Standard of Care
2015.
-Testing is also recommended for asymptomatic adults of any age who are overweight or obese
and who have one or more additional risk factors for diabetes.(Standards of Care, 2015)

4. Describe the 3 Ps (polyuria, polyphagia, polydipsia) associated with the onset of DM and
describe the pathophysiology for why each occurs.

-Polyuria: increased urine: The excess glucose in the urine filtrate acts as an osmotic
diuretic causing a large volume of water to be lost in urine instead of being reabsorbed
-Polydipsia: increased thirst: The loss of fluid from excess losses in urine causes a drop in
blood volume and hydration. The dehydration triggers thirst.
-Polyphagia: increased hunger: The bodies inability to uptake glucose for energy signals
hunger (Spencer, 2009)

5. 60-70% of people with DM will develop some form of neuropathy. What are Diabetic
Neuropathies? What are at least 3 of the causes of diabetic neuropathies? List at least 4 Symptoms
of Diabetic Neuropathies.

-Diabetic neuropathies are nerve damaging disorders associated with diabetes mellitus.
These conditions are thought to result from diabetic microvascular injury involving small
blood vessels that supply nerves (Wikipedia, 2016)

- 3 causes of diabetic neuropathy are:

1. Hyperglycemia, the high levels of blood glucose are associated with nerve damage,
 2. Inflammation in the nerves that is caused by an autoimmune response. This occurs
when your immune system mistakenly attacks part of your body as if it were a foreign
organism.
3. Genetic factors unrelated to diabetes that make some people more susceptible to nerve
damage.
4. Smoking and alcohol abuse, which damage both nerves and blood vessels and
significantly increase the risk of infections. ("Diabetic Neuropathy", 2016)

- Symptoms of Diabetic Neuropathies are:

"numbness, tingling, or pain in the toes, feet, legs, hands, arms, and fingers
wasting of the muscles of the feet or hands
indigestion, nausea, or vomiting
diarrhea or constipation
dizziness or faintness due to a drop in blood pressure after standing or sitting up
problems with urination
erectile dysfunction in men or vaginal dryness in women
weakness( Nerve Damage (Diabetic Neuropathies) | NIDDK.)

6 List the 4 different neuropathies that may occur. For each, list two ways it may affect the body or
the patients ability to function.
(Use http://diabetes.niddk.nih.gov/dm/pubs/neuropathies/)

1. Peripheral neuropathy, the most common type of diabetic neuropathy, causes pain or loss of
feeling in the toes, feet, legs, hands, and arms. loss of feeling in feet can lead to infection if
they do not notice a cut-

2. Autonomic neuropathy causes changes in digestion, bowel and bladder function, sexual
response, and perspiration. It can also affect the nerves that serve the heart and control blood
pressure, as well as nerves in the lungs and eyes. Autonomic neuropathy can also cause
hypoglycemia unawareness, a condition in which people no longer experience the warning
symptoms of low blood glucose levels. Hypoglycemia unawareness-

3. Proximal neuropathy causes pain in the thighs, hips, or buttocks and leads to weakness in the
legs. may make it hard to be mobile-

4. Focal neuropathy results in the sudden weakness of one nerve or a group of nerves, causing
muscle weakness or pain. Any nerve in the body can be affected.- pain can decrease
mobility- (Nerve Damage (Diabetic Neuropathies) | NIDDK.)

7. Karen has started taking Metformin for diabetes management. What are the 2 main mechanisms
of action for metformin?

- Suppresses hepatic glucose production & increases insulin sensitivity in hepatic and
peripheral tissues.
 8. How does the doctor determine whether Metformin should be used solely as the first
pharmacology intervention vs. combination therapy?

-If diet and exercise are not enough alone to control blood glucose levels they will prescribe
a pharmocolgic agent like Metformin. If they suspect non-compliance or if A1c levels are
high they may begin with combination therapy.

- Most leading guidelines suggest adding one of several antihyperglycemic drugs when
lifestyle and metformin fail to keep A1C at target unrelated to these questions. The previous
American Diabetes Association (ADA)/European Association for the Study of Diabetes
(EASD) consensus statement suggested a preferable order of drugs , while the AACE/ACE
Diabetes Algorithm for Glycemic Control suggested starting treatment with
combination therapy in nave patients with A1C >7.6% . The Canadian Clinical Practice
Guidelines suggested adding one of several second drugs after metformin in patients with
A1C >7% (Raz, 2013)

9. Describe the potential drug nutrient interactions or side effects of the following medications the
patient is on:
Drug Purpose of drug Drug-nutrient Side effects
interactions
Metformin Antihyperglycemic Avoid alcohol, guar Anorexia, stable wt or wt loss,
gum>6hrs after drug decreased folate and Vit B12
absorption, metallic taste, dyspepsia,
N/V, bloating, diarrhea, falatulence,
constipation, headache, fatigue, muscle
pain, dyspnea, rash, increase sweating,
chills, flu syndrome, flucshing, chest
discomfort, palpitations, dizziness,
asthenia.
Omeprazole Anti ulcer/ Take 30-60 min before Avoid: SJW, gingko, alcohol. Decreases
Antigerd meal- May: reduce C GI secretion, Increases gastric pH,
absorption by up to 61%, nausea, abdominal pain, diarrhea,
decrease absorption of headache, dizziness, cough, rash,
FE and Vit B12 muscle/back pain, Rare: hepatitis,
pancreatitis, pneumonia, Increases:
Gastrin- <1%- AST, ALT, alkphos, LDH,
GGT, chol, glucose, crea, dyscasis
Lowers Vitamin B12
Chlorthalidone Antihypertensive, Take in AM w/ food, Anorexia increased thirst, dry mouth,
Diuretic Avoid Natural Licorice, N/V, GI irritation, diarrhea,
Limit Alcoholmay need constipation, increase glucose,
decreased Na & cal, decreases BP w/possible hypotension,
increased K & Mg diet (or dizziness, weakness, photosensitivity,
K or MG supplement),
caution w. Vit c or Vit D
supplement
Zoloft Antidepressant Avoid Tryptophan Anorexia, weight loss,, dry mouth, N/V,
supplements, Avoid SJW, dyspepsia, diarrhea, constipation,
Caution w/Grapefruit insomnia, dizziness, drowsiness,
juice/related citrus, avoid increased sweating, tremor, twitching,
 alcohol headache, sexual dysfunction, low
thyroid function
Temazepam Sleep Aid Caution with soy or egg Anorexia, decreased weight, increased
allergy, avoid appetite, increased thirst, dry mouth,
alcoholLimit increased salivation, N/V, constipation,
caffeine<400- diarrhea, drowsiness, sedation, ataxia,
500mg/day, caution fatigue, dizziness, confusion, slurred
w/sedative herbal speech, headache, tremor, blurred
products or stimulant vision, depression, hypotension,
products tachycardia, palpitations, anterograde
amnesia, urinary retention or
incontinence

10. Karen has not been testing her blood glucose at home. SMBG is an important aspect of overall
management of diabetes. What should be the patients pre-prandial goals (includes fbg) and 2
hour post-prandial goals? What would you say to the patient to emphasize the value of SMBG?

-FBG: <90
- Preprandial capillary bg : 80-130
-2hr postprandial capillary bg: <120 (peak post prandial <180)

-SMBG is very important for pattern management and ideal control & prevention of hypo&
hyperglycemia.- We need to see the trends to know if/when to adjust- It has been shown to
improve HgA1c levels and lower rates of micro& macrovascular diseases. Careful
monitoring of bg levels may slow its progression and curb symptoms.

11. People with diabetes have increased risk for depression and Karen has been diagnosed with
clinical depression. Describe how depression can affect diabetes management. When are the most
opportune times to screen for depression?

-Depression can cause a lack of energy and they may feel like SMBG to labor intensive,
exercising is too intensive, may not have high priority on maintaining health, they may not
feel hungry, so they do not eat which affects bg levels.

-It is important to screen for depression at diagnosis and optimally at every checkup with a
quick assessment/screening tool or when pt reports symptoms.

II. Nutrition Assessment

12. Assess Karens weight and BMI. What would be a healthy weight range goal?

-332.4#, 67, BMI:52.1 Pt is currently morbidly obese

For her height appropriate weight range would be: 139 - 186#.
-Since she is morbidly obese I would go with the high of the 2 numbers, 186# range.

13. Calculate Karens energy and protein recommendations for weight maintenance. Also calculate the
energy level you would recommend for weight loss.

-Energy=(9.99 X 151kg) + (6.25 X 170.2) (4.92 X 55) 161=2141 kcal

-AF 1.3 difficulty /no walking-ADLs
 2141 X 1.3 = 2783 kcal
-Protein: = 332.4# x .454= 151 kg.151kg x .8= 121 g protein/day

-Energy Level for weight loss weight loss goal of 23.8# = 83,300kcal
83300/(180)=463 per day deficit needed. 2330-463= 1867kcal
-Recommend 1850 kcal/day

14. You will work with the client to determine an initial weight goal. What is the general
recommendation for amount of weight to lose in the first 6 months?

-The general 6 month wt loss recommendation is 5- 10% of current body weight.

- 332.4 x .05= 16.6# 332.4 x .10 = 33.24 # - since obese I would aim for 10% loss- 33#

III. Nutrition Therapy

15. The current standard for MNT for type 2 dm is CHO counting. Describe what this is.

-Carbohydrate counting is adding up the carbohydrates you will consume prior to that meal and
adjusting your insulin dose off of that (+ adjustment for current blood sugar levels) Carbohydrate
counting breaks down food groups into what serving size = 15 g of carbohydrate for ease of use.
For example, 1 slice of bread, c. cooked oatmeal, 1 cup milk. 1 small banana all contain apx
15g of carbohydrate.

16. What is the ideal macronutrient distribution for someone with diabetes? (Fat, Protein, CHO)
-There is none, the best distribution is whatever the patient will adhere to long term.

IV. Nutrition Diagnosis

17. Write two PES statements for your client. One should be from the clinical domain the 2nd one should
be from the behavioral domain.

NB1.1 Food and Nutrition-related knowledge deficit related to new diagnosis of T2DM as evidenced by
high FBG levels of 168mg/dL and high HbA1c level of 7.1%

NC-2.2 Altered nutrition related lab values: FBG, HbA1c, Chol, Trig, cLDL, Chol/HDL ratio RT diet
high in carbohydrates and saturated fat AEB levels at admittance of HbA1c 7.1%, FBG 168mg/dL, Chol
219mg/dL, Trig 202mg/dL, cLDL 138.6, Chol/HDL ratio of 5.48% compared to FBG of <100, HbA1c
<5.6%, Chol of <199, Trig of <200, cLDL of <99 and Chol/HDL ration of <5%

V. Nutrition Intervention

18. List 4 questions you would ask Karen about her eating habits to help you determine initial
recommended diet changes.

1. What do you like to eat/eat on a typical day? (Understand what type of food pt currently eats
and likes.)
2. How many times do you eat in a day, what amounts at each meal?
3. What are some items you cook at home?
4. What are some premade items (frozen or from restaurants)? (Could look up info for favorite
frozen/restaurant meals)
19. For each of the PES statements you wrote, identify an Intervention using the IDNT/NCP
terminology and codes. Also provide a brief description of your plan based on the pts needs/goals
for each intervention.

ND-1.2.4.3 Decreased Carbohydrate diet -ND-4.5 Menu Selection Assistance- Providing

ND-1.1 General Healthful diet plan coordinated with patient E-1.4 with the purpose of nutrition
relationship to health/disease
Plan: Begin on CHO counting program start with 60g@ each of 3 meal and 2 snacks @ 15geach
for a total of 210g CHO a day

ND-1.2.5- Fat-modified diet:

Plan: Reduce overall fat composition and consumption of saturated fats- increase unsaturated
fats.

20. While it is best to individualize the diet plan, this can be difficult to do until you get to know the
patient better. What starting level of CHO distribution would you recommend for this client and why?

130g CHO/day divided by 3 meals and 2 snacks.

21. Karen also has HTN (hypertension) and HLP (hyperlipidemia). On future visits, what other
recommendations should be considered to assist in management of these co-existing conditions?

HTN: Dietary modifications that lower BP: salt intake, weight loss, and moderation of alcohol
consumption (pt denies alcohol consumption)

HLP: Dietary modification that lower Lipid levels: Reduce overall fat consumptions, reduce
saturated fat, increase fiber, increase exercise.

22. We know that physical activity is important for all children and adults. Discuss how physical activity
can impact blood glucose levels. Will exercise impact any other aspects of the patients medical history?

Exercise can lower blood glucose levels because the muscles use circulating glucose for energy.
Exercise can also help to treat HTN and HLP.

23. Karen states she cant start a walking program due to pain in her lower back
and her right leg. She also states it is very hard to find time to exercise. Water
exercises are incompatible with her work schedule. What recommendations would you give Karen to
help her start an exercise program?

-Chair exercises would be a way to begin to incorporate exercise into her daily schedule, could
use resistance bands to increase strength, yoga videos at home any exercise now may increase
her strength, decrease pain and make walking more manageable. She could still join a gym or
public pool and do some swimming or water aerobics on her own even if no classes are running
at that time.

VI. Nutrition Monitoring and Evaluation.

24. You have scheduled Karen to have a follow-up visit in two (2) weeks. List 4 things you will assess.
Use the monitoring and evaluation (M/E) codes for each of the 4 items.

- FH-1.5.5.1 Total Carbohydrate Intake

 - FH-1.2.2.2 Types of food/meals
- FH-1.5.1.2 Saturated Fat Intake
- BD-1.5.1 Fasting plasma glucose

25. It is now 6 months later and Karen has lost 12#. Her blood glucose levels are within goal 72% of the
time. Are you happy with her progress? The doctor has again asked her to consider bariatric surgery. List
two advantages and two disadvantages to bariatric surgery.

-I think she could have done a better job with her weight loss, but it is positive that she has been
able to be within he blood glucosegoal 72% of the time. After 6 months she has only lost 3.6% of
her body weight. A 2# wt loss per month is low for someone with such a high BMI.

-Two advantages are: weight loss and restriction in amount that they can eat in one sitting.

-Two disadvantages are: I can see hypoglycemia being an issue if they do not eat enough CHO in
a sitting, as well as slow healing

26. The physician is considering adding Glucotrol to achieve better glycemic control. Describe how
Glucotrol works to improve glucose levels. Discuss potential side effects and any food interactions.

-Glucatrol is a Sulfonylurea, it lowers blood glucose levels by increasing the pancreass secretion
of insulin. Patients should avoid alcohol while on this medication. Potential side effects include:
dyspepsia, nausea, diarrhea, constipation hypoglycemia, dizziness, headache, drowsiness, blurred vision
and skin reactions.
27. Write either an ADIME or SOAP note for your client. Worth 4pts

A: Assessment
Pt. Is newly diagnosed with type 2 DM, c/o pain in her back and legs that prevent her from
walking, neck pain, headaches and Pt suffers from depression. Pt denies ETOH and smoking,
does not exercise.

55 yo Female
179% DBW Ht: 67, wt: 332.4#, BMI= 52.1 Morbidly Obese
Medical dx: T2DM, HLP, HTN, depression, Morbidly Obese
Current Diet order: N/A
Pertinent medications: Metformin XR, Chlorthalidone, Cardizem, Omeprazole, Zoloft,
Temazepam
Pertinent lab values: HbA1c 7.1% (H), FBG 168mg/dL(H), Chol 219mg/dL(H),
Trig 202mg/dL(H), cLDL 138.6 (H), Chol/HDL ratio of 5.48% (H), Vit D
21.2NG/ML (L)
FH-1.2.2.1 Energy Intake Daily energy intake as calculated by Mifflin of
2783kcal/kg/bw to maintain wt. FH 1.62 Estimated protein intake: approximately
121g/kg/bw

D: Diagnosis
NB1.1 Food and Nutrition-related knowledge deficit related to new diagnosis of T2DM as
evidenced by high FBG levels of 168mg/dL and high HbA1c level of 7.1%

Goal: Increase food knowledge and program adherence while decreasing inconsistency of
staying within preset carbohydrate goal amounts at meals.
Objective: To consume a consistent amount of carbohydrates at each meal at predetermined level

I: Intervention
ND-1.2.4.3 Decreased Carbohydrate diet -ND-4.5 Menu Selection Assistance- Providing
ND-1.1 General Healthful diet plan coordinated with patient E-1.4 with the purpose of nutrition
relationship to health/disease

Plan: Begin on CHO counting program start with 60g@ each of 3 meal and 2 snacks @ 15geach
for a total of 210g CHO a day

Objective: to lower and maintain blood glucose levels.

M: Monitor
- FH-1.5.5.1 Total Carbohydrate Intake
- FH-1.2.2.2 Types of food/meals
- FH-1.5.1.2 Saturated Fat Intake
- BD-1.5.1 Fasting plasma glucose

E: Evaluation
AD-1.1.4 Weight Change
AD-1.15 Body Mass Index
Laura Wendte, RDTB 10-18-2016

References:

1. Spencer, J. (2009, October). Polyuria, Polydipsia and Polyphagia - Three Signs of Diabetes.
Retrieved October 26, 2016, from http://insulin-glucagon-and-
diabetes.blogspot.com/2009/10/polyuria-polydipsia-and-polyphagia.html

2. 2. Mahan, L. K., Escott-Stump, S., Raymond, J. L., & Krause, M. V. (2012). Krause's food & the
nutrition care process. St. Louis, MO: Elsevier/Saunders.

3. 4. Standards of Care. (2016). Retrieved October 17, 2016, from

http://professional.diabetes.org/CONTENT/CLINICAL-PRACTICE-RECOMMENDATIONS

4. Diabetic neuropathy. (2016, October). Retrieved October 26, 2016, from

https://en.wikipedia.org/wiki/Diabetic_neuropathy

5. Nerve Damage (Diabetic Neuropathies) | NIDDK. (n.d.). Retrieved October 26, 2016, from
https://www.niddk.nih.gov/health-information/diabetes/preventing-diabetes-problems/nerve-
damage-diabetic-neuropathies

6. Raz, I., MD. (2013, August). Guideline Approach to Therapy in Patients With Newly Diagnosed
Type 2 Diabetes | Diabetes Care. Retrieved October 27, 2016, from
http://care.diabetesjournals.org/content/36/Supplement_2/S139